Download CYRIAX Transverse Friction Massage

CYRIAX
Transverse Friction Massage
Effects
Deep transverse friction has three main effects :
* Traumatic hyperaemia, which helps to evacuate pain triggering metabolites.
* Movement of the affected structure, which prevents or destroys adhesions and
helps optimize the quality of the scar tissue.
* Stimulation of mechanoreceptors, which produces a quantity of afferent impulses
that stimulate a temporary analgesia. This also helps the patient to perform
movement exercise.
Indications-contraindications of friction massage
Indications : muscular, tendinous and ligamentous lesions.
Contraindications :
*
*
*
*
Calcification
Rheumatoid tendinous lesions
Local sepsis
Skin diseases
Technical details
• Exact localization
It is imperative that deep friction is given at the site of the lesion ; after all, it is
there where we need to influence the scar formation.
• No movement between finger and skin
We need to friction the structure and not the overlying skin. Do not glide over the
skin, otherwise you might damage the skin, making deep friction impossible for the
next session(s).
If the patient used a creamy body lotion then cleansing the skin with alcohol or use
a thin layer of cotton-wool between the finger and skin.
• Transverse
Deep friction is given transverse to the fiber direction.
• Sufficient amplitude
Make sure we make a big movement and move over-up-and again over the
structure in order to have a good contact. Therefore it is necessary to take a
reserve of skin : first we move the skin superficially in the opposite direction and
then we apply pressure and perform the active phase of the deep friction.
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• Sufficient depth
How deep must the deep friction be ? Sufficient to reach the structure ; so, it
depends on the location of the structure.
• Starting position
Make sure the friction massage is comfortable for you as well for the patient.
Position the patient in a way where you can easily reach the structure you want to
friction. Make sure your position is comfortable also in order to save energy.
Make the lesion accessible to the finger. Tendons with a tendon sheath are
generally frictioned in a stretched position, just like ligaments (better contact).
Muscle bellies are always frictioned in a shortened position (easier to move the
fibers in relation to each other).
• Various grips are used, according to the nature and the position of the lesion.
• Economy of effort :
concentrate on performing an arm movement instead of a small finger movement
since this is much more comfortable to the patient and to the therapist.
Make sure you make a two-phase movement : active phase with more pressure
(movement of the structure) and relaxation phase, without pressure.
Always try to keep your own finger joints slightly flexed (if you friction too much
with your interphalangeal joints in hyperextension, you might provoke a traumatic
arthritis in those joints).
Duration and frequency
* For most lesions, 3 times/week is sufficient frequency : usually 15' per session ;
we start the first session with 10'. In some chronic lesions the duration of
treatment will reach 20'. If more than one spot has to be treated (e.g. achilles
tendinitis), it will be 10' per localization.
* There are two exceptions where a different strategy is used : the medial collateral
ligament of the knee and the lateral ankle ligaments. Here, the deep friction is
given
in a progressive way. The details will be discussed in the appropriate sections.
* If the structure is too tender on palpation, the interval between the sessions is
prolonged ; the duration and the intensity of the deep friction do not change.
* The treatment can be ended when the patient is symptomfree and the functional
examination has become negative ; remaining local tenderness on palpation can be
ignored.
Exception : quadriceps and hamstrings muscle bellies ; To avoid recurrences, the
treatment has to be continued for another week after full clinical recovery.
Normal execution
When describing the techniques in detail, the "normal execution of the deep
friction"
will often be mentioned. What we mean by that is : one or more fingers are put
onto the lesion, reinforced by one or more fingers. A reserve of skin is taken in the
opposite direction, pressure is applied and the active phase of the DF is then a
movement towards ourselves. In most cases, this is a large arm movement and not
a small finger movement, with all our finger joints slightly flexed. The relaxation
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phase then follows into the opposite direction.
Remark : sometimes all fingers are used next to each other for DF, i.e. when
treating muscle belly lesions in large muscles. This is necessary to prevent the
formation of adhesions. When the DF is given tenoperiostally, there should always
be a contact with both tendon and bone.
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Shoulder techniques
Acromioclavicular joint friction massage
We palpate cephally in the deltoid area till we
reach the lateral edge of the acromion. The joint
line lies 1-1 ½ cm more medially.
The deep friction is the normal execution with the
ipsilateral index finger, reinforced by the middle
finger. A large amplitude is needed.
Supraspinatus tenoperiostal friction massage
The patient sits with his arm behind the back (medial rotation makes the insertion
of the tendon, now lying in front of the acromion, accessible to the finger). We can
palpate the spine of the scapula in a lateral
direction ; as soon as we lose contact with the
bone, we come back onto the bone and
palpate now in an anterior direction. We know
for sure that we are on the acromion. The
tendon, with its insertion on the greater
tuberosity, is found just beyond the anterior
edge of the acromion.
The deep friction is done in the normal way,
with the index finger of the ipsilateral hand,
reinforced by the middle finger. The thumb
should be placed quite far down the arm. So
that a downward pressure is exerted on the
greater tuberosity, the index finger-nail
remaining horizontal. (Were the thumb to be
put posteriorly, with the nail of the index
finger pointing anteriorly, a pressure would be
exerted to the front of the acromion and the
lesion would be missed. This is frequently made error.)
It is possible that there is minor tenderness on palpation, but more tenderness
lateral and medial to the structure. Don't be confused by this fact ; it is possible
that poor vascularization of the tenoperiosteal area causes this discrepancy in
symptoms
Supraspinatus musculotendinous junction friction massage
The arm rests in about 90° of abduction. The
therapist stands at the other side and uses the
middle finger of the ipsilateral hand, reinforced
by the index finger. We palpate the space
between the spine of the scapula and the
clavicle, towards the lateral direction, and look
for tenderness. The palpation is a
pronation/supination movement with flexed
middle finger.
This deep friction is an exception to the general
rule, because now there are two active phases
instead of an active and a relaxation phase. We
use the middle finger to obtain equal range in
both directions. Make sure to perform a large
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movement and avoid extending the distal interphalangeal joint (otherwise you will
loose good contact and also damage your own interphalangeal joint) .
Infraspinatus tenoperiostal friction massage
The patient lies in the sphinx position (prone on elbows) : 90° of elbow flexion, with
the shoulder in slight lateral rotation and adduction. This is the best, but not always
the most comfortable position (e.g. elderly patients or some back patients). For
that reason there exists an alternative in side-lying, where the same components
as in the sphinx position can be built in.
Technique : the palpation, in view of
finding the precise localization, is a
supination movement with flexed thumb.
In this way, when palpating under the
spine of the scapula, in a lateral direction,
the difference between muscle belly (soft),
tendinous body (cable), insertion (cable
and bone) and beyond the insertion (bone
without cable) can clearly be felt.
The deep friction itself is taking a reserve
of skin in a pronation direction first, then
applying pressure and performing the
active phase of the movement, which is a
supination. Since the skin in this area is so
vulnerable, a thin layer of cotton-wool is
used between the patient's skin and our
thumb.
It is best to perform this technique with both hands, whereby one thumb reinforces
the other. Make sure the frictioning thumb stays flexed, otherwise you loose good
contact.
Subscapularis tenoperiostal friction massage
Palpation : for a right subscapularis, we
palpate with the left thumb under the
clavicle in a lateral direction ; we reach the
coracoid process. We move caudal and
laterally again till we feel the lesser
tuberosity (check : lateral to this bone we
find the bicipital groove). Back to the lesser
tuberosity, thumb in a 45° direction pointing
to the nipple, make a large movement of the
thumb forwards (taking the skin with us) and
back to the lesser tuberosity with the thumb
well flexed. The purpose is to keep a deltoid
border behind our finger, so that we can
reach the structure in a more optimal and
direct way. While performing this backward movement we feel one or two tendons
slip under our thumb (short head of biceps and coracobrachialis) and, if we keep
our thumb flexed, we do not lose the anterior edge of the deltoid muscle. Now we
bring our thumb back in a longitudinal direction for the deep friction.
This will be a large rolling movement of the arm cephally, with the thumb as flat as
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possible , for the patient's comfort. However, a slight degree of flexion is
permanently needed, in order to keep the edge of the deltoid behind our thumb
during the entire friction. So we cannot release the pressure completely on the way
back as in a normal deep friction.
Biceps, caput longum friction massage
Palpation : see technique for the subscapular
tendon.
With the patient's arm in lateral rotation, the
contralateral thumb is put longitudinally into the
groove and pressure is exerted sideways. The
active phase of the deep friction is a medial
rotation with the other arm, while the thumb
exerts pressure.
Remark : the groove can easily be felt, but the
tendon is not always felt (depends probably on the
height of the bony edges of the groove).
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Elbow techniques
Biceps muscle belly friction massage
The muscle is in a relaxed position. The precise
site of the lesion is found on palpation. The deep
friction is a pinching technique ; the fingers are
applied anteriorly to the muscle and a reserve of
skin is taken in a posterior direction. Then
pressure is applied (the pinch is closed as it were)
and the active phase is a straight forward
movement. We feel the fibres of the biceps slide
under our fingers. Avoid making a circular
movement and flexing too much the interfalangeal
joints
Biceps insertion friction massage
We palpate the joint line between humerus
and radius. Two cm more distally, the flexed
thumb is applied quite medially, with the
patient's arm in supination. The thumb is set
in sharply and deeply.
The active phase of the deep friction is
bringing the patient's arm in pronation while
exerting pressure with the thumb. At around
¾ of pronation, the biceps insertion slips
under our thumb. The pressure is released
on the way back. Some discomfort during
this friction is normal
Triceps friction massage
The starting position is 90° flexion and
supination. The deep friction is the normal
execution with 1-3 fingers, according to the
size of the lesion, and with the thumb as a
fulcrum anteriorly.
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Supinator friction massage
The starting position is ¾ extension and
pronation. We find the precise spot by
palpation : we palpate in the zone
between radius and ulna. For a right
elbow, the flexed left thumb is used,
between radius and ulna. (Avoid putting
the thumb cranial to the radius, in the
extensor muscles.) A reserve of skin is
taken in an oblique cranial direction. The
deep friction is an active movement in an
oblique downward direction. It is a
smooth arm movement, rather than a
pure thumb movement. Notice that there
is not much space.
Remark : make sure you have space to perform an arm movement during the
friction.
Pronator teres friction massage
During palpation, we ask for a slight contraction
towards pronation to make sure that we find the
correct structure. The deep friction is the normal
execution.
Tennis elbow type 1 friction massage
The starting position is 90° elbow flexion and supination. We palpate the lateral
aspect of the lateral epicondyle, we put our
thumb a little bit higher until we reach the
sharp edge just above the lateral epicondyle.
We flex the thumb 90°, so that the thumb-nail
now faces forwards. A reserve of skin is given
upwards and pressure is applied on the
anterior aspect of humerus. The active phase
of the deep friction is an arm movement
downwards with pressure in a posterior
direction, followed, as always, by a phase of
relaxation.
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Tennis elbow type 2 friction massage
The starting position is 90°
flexion and supination. The
therapist's thumb is 90°
flexed, with the tip of the
thumb lateral to the lateral
epicondyle. The deep friction
has to be given at the front of
the epicondyle, therefore he
brings his thumb now onto the
anterior aspect of the bone.
The correct spot is reached
when only a very small range
of movement is possible (a
translation movement in a
medial direction) and when the
movement stops with a harder
end-feel. The other fingers act as a fulcrum at the medial side of the elbow. The
active phase of the deep friction is a translation movement at the front of the
lateral epicondyle, with pressure applied in a medial/downward direction.
To avoid losing contact with the lesion, the patient should not abduct his arm, nor
should our thumb be put too high or too flat.
Using a layer of cotton wool between finger and skin could be used to prevent
damage to the skin (short finger nails are an advantage).
Tennis elbow type 3 friction massage
The starting position is ¾ of extension and
pronation. First look for the precise localization :
the tendon level with the joint line or with the
radial head. The thumb is put as flat as possible
on the lesion, a reserve of skin is taken in a
medial direction, pressure is applied and the
active phase of the deep friction is a movement in
a lateral direction.
Tennis elbow type 4 palpation
The starting position is 90° flexion and supination.
Level with the neck of the radius, a pinching grip
with all fingers is used ; the muscle belly is lifted
upwards as it were. This results automatically in a
visible wrist extension.
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Golfer elbow friction massage
Complete elbow extension. We find the
medial epicondyle and proceed to the front
of it. Deep friction as normally executed.
Remark :
- at the tenoperiosteal junction deep friction
is a straight line movement and the feel is
rather hard ;
- at the musculotendinous junction the deep
friction is a more ample round movement,
and the feel is softer.
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Wrist and hand techniques
Dorsal carpal ligament friction massage,
proximal or distal row
The wrist is held flexed ; the therapist sits at the
patient's ulnar side, close to the treatment table, the
patient's arm slightly outside the couch. For a right
wrist, the deep friction (lateral-medial) is the normal
execution with the right index finger, reinforced by the
middle finger.
Dorsal carpal ligament friction massage,
middle row
The wrist is held flexed ; the therapist faces the patient. The deep friction (cephalcaudal) is the normal execution with the tip of the thumb.
Extensor carpi radialis longus or brevis friction massage
The therapist sits at the patient's ulnar side close to the treatment table, the
patient's arm slightly outside the couch ; the wrist is held in flexion. Deep friction is
normally executed with the index finger reinforced by the middle finger.
The longus inserts radially on the base of the second metacarpal bone ; the brevis
radially on that of the third metacarpal bone.
Extensor carpi ulnaris friction massage
The wrist is held in radial deviation. The deep friction is executed normally with the
index finger, reinforced by the middle finger.
Flexor carpi radialis friction massage
The wrist is held in extension ; the deep friction is
executed normally with the thumb.
Flexor digitorum friction massage
The wrist and the fingers are held in extension. The deep
friction is executed normally with four fingers, the thumb
acting as a fulcrum.
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CMC 1 joint friction massage anterior part
Palpation of the joint can be done as
follows. During passive ab- and
adduction, or flexion and extension
movements, we palpate the first
metacarpal bone in a proximal direction ;
first we feel only bone, then we reach the
joint line and, consequently, we feel
movement.
For a left hand (palm facing upwards) the
right thumb is put at the front of the joint
and the thenar muscle is pushed aside.
The capsule is slightly stretched by an
extension-backward movement of the
patient's thumb. The active phase of the
deep friction is a supination movement of
the forearm. Make sure the patient's hand is outside the couch, so that there is
enough space for the therapist's arm to perform the movement.
CMC 1 joint friction massage lateral part
Changing from the anterior to the lateral part of the joint is as follows : the
patient's hand is brought in a vertical position, we change thumbs (to allow our
thumb to relax 5'), move laterally and stretch the capsule by bending the patient's
thumb. The deep friction is executed normally.
Tenosynovitis tunnel 1 and 3 friction massage
The patient's wrist and thumb are flexed. Our thumb is put longitudinally onto the
lesion, a large reserve of skin is given towards
pronation, after which the deep friction is a
supination movement with the ipsilateral hand.
Interosseus muscle belly friction
massage
The patient's hand lies flat on the couch with the
fingers slightly spread. This deep friction is an
exception to the two phases rule (active phase
followed by a relaxation phase). The deep
friction, with a slightly bent middle finger, is a
pro-supination movement, in which the pressure
not released, i.e. both movements are active
is
phases.
Interosseus tendon friction massage
In order to reach the fairly palmarly situated
tendon, we have to create some room for our
thumb. Our middle finger pushes a knuckle up,
our thumb pushes the other knuckle down.
The deep friction is a supination movement
with the tip of the thumb.
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Hip techniques
Adductor longus musculotendinous
junction friction massage
Starting position : slight abduction and
lateral rotation. The deep friction is a
pinching technique with thumb and fingers,
with the heel of the hand as a fulcrum. A
large reserve of skin is taken in a lateral
direction, then pressure is applied and the
active phase of the deep friction is a
horizontal movement in a medial direction.
Adductor longus tenoperiostal
friction massage
Starting position : slight abduction and
lateral rotation. For a right adductor longus
we palpate in the cranial direction with the
left middle finger until we feel the inferior
edge of the pubic bone : the finger is then
turned 45° medially and now feels bone and
tendon at the same time. It is reinforced by
the other middle finger. The deep friction is
executed normally.
Psoas muscle belly friction massage
The patient adopts the half-lying position. Site
of the lesion : below the inguinal ligament and
medial to the sartorius muscle. For a right
psoas muscle, we use the right index and
middle fingers, reinforced by the left middle
and ring fingers. Make sure that during the DF
you keep a deep contact.
Remark : for the patient's comfort, it is
essential to keep the fingers horizontal and to
increase the pressure gradually.
Rectus femoris tendon friction
massage
The patient sits with 90° hip flexion. We find
the tendon just lateral to the sartorius muscle.
For a right rectus femoris, the flexed fingers of
the left hand, reinforced by the fingers of the
other hand, grasp the tendon. The deep
friction is the normal execution with an active
phase towards the therapist.
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Iliotibial band friction massage
The patient lies on his side with a
cushion between his knees.
The therapist takes a reserve of skin
towards himself, then puts the thumb
onto the lesion and reinforces it with
the heel of the other hand ; both arms
are extended. The deep friction is the
normal execution, in which the active
phase is a forward movement of the
entire trunk. The patient's pelvis is
stabilized by the therapist's thigh and
fingers.
Hamstrings muscle belly friction
massage
The muscle is in a fully relaxed position
(prone lying, knees 90° flexed). The deep
friction is the normal execution with all
fingers, covering a large area in order to
limit the risk of adhesion formation.
Hamstrings origin friction massage
The patient lies on his side with the hips and the
knees in 90° flexion. The deep friction is
executed normally with two or three fingers ;
they feel the ischium and the tendons at the
same time.
Remark : it is easier to work in close contact
with the patient on a higher treatment table.
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Knee techniques
Medial collateral ligament friction massage
The friction is given in as much extension and flexion as possible. The knee is
supported by a cushion. For a left knee, we use the left middle or index finger ; we
find the joint line and we palpate in a posterior direction until, beyond the midline,
the ligament is found (a large flat structure). The deep friction is the normally
executed.
For the deep friction in flexion, we find the lesion in extension first, keep our finger
on it, and bend the knee. The deep friction, again, is the normal execution. Notice
that the direction in which the ligament now lies has changed, and so has the
direction of our friction.
Lateral collateral ligament friction massage
The knee is extended ; we palpate the joint line in a
posterior direction. We feel, successively, bone, then a
thin flat structure (iliotibial tract), bone again and then a
tendon-like structure, the LCL. Even more laterally, the
biceps tendon can be found.
The DF is the normal execution.
Medial coronary ligament friction massage
The starting position is 90° flexion and lateral rotation.
For the left knee, we place the left index finger onto the
tibial plateau. The finger nail faces upwards ; in this way,
pressure can be applied in a downward direction. The
thumb should be put far down, in order to maintain this
pressure. The deep friction is normally executed.
For a lateral coronary ligament, the knee is in medial
rotation.
Quadriceps muscle belly friction massage
The muscle is in a shortened position, i.e. with the
patient sitting, without a cushion under the knee.
Large contact with both hands ; the deep friction is
the normal execution with all fingers. The active
phase of the DF is reinforced by a backward
movement of the trunk ; the relaxation phase is the
forward movement.
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Quadriceps infrapatellar/suprapatellar friction massage
Suprapatellar : the distal half of the
patella is pushed in a posterior direction,
so as to make the proximal part tilt
forwards, which makes it easier to reach
the lesion. The deep friction is the normal
execution with the ring finger, reinforced
by the middle finger, using the thumb
more distally as a fulcrum. The pressure
is applied towards the toes.
Since the lesion lies tenoperiosteally,
there is contact with the contractile
structure and the bone at the same time.
Infrapatellar : now, the upper half of the
patella is pushed posteriorly. The deep
friction is the same as above.
Quadriceps parapatellar medial friction massage
For a left knee, the right thumb pushes the patella in a
medial direction. The left hand is in supination ; the
ring finger, reinforced by the middle finger, exerts an
anterior pressure on the back of the patella.
The deep friction is the normal execution, i.e. a reserve
of skin in a cranial direction, then pressure is applied,
the active phase is a caudal movement with pressure in
an anterior direction. It is an arm not a finger
movement. The forearm remains parallel to the
patient's leg. For practical reasons, the deep friction is
done in a caudal direction.
Biceps femoris tendon friction massage
The patient lies prone with his foot beyond the
edge of the couch. He actively holds his foot up
for a moment, to enable us to find the tendon
more easily. The deep friction is the normal
execution with 1, 2 or 3 fingers, according to the
size of the lesion.
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Pes anserinus friction massage
We palpate the soft structures from distal to
proximal until we find the bony edge of the
tibia, then we move 1 cm distally again. The
fingers are applied in a 45° medialdownward direction. The deep friction is the
normal execution with four finger tips,
reinforced by the other hand.
Popliteus muscle belly friction
massage
The patient lies prone with his knee slightly bent.
We first palpate the head of the fibula, then 1 ½ cm
cephally up the joint line, and another 1 ½ cm
cephally lies the insertion on the lateral femoral
condyle. From here, we imagine a 45° line caudally
and the muscle belly lies fanwise around this line.
We look for the most tender spot, pull the skin
towards us (= reserve of skin) and apply the flat
thumb on the lesion. It is reinforced by the heel of
the hand ; the therapist's arms are straight. The
deep friction consists of an active phase mediallyupwards, followed by a relaxation phase. It is more
a trunk movement than an arm movement. In order
to work comfortably, the pressure is only gradually
increased.
Popliteus origo friction massage
Starting position : 90° knee flexion. About 1 cm
from the edge of the femoral condyle, we find a
vertical sulcus, containing the popliteal tendon. The
deep friction is performed by the left or the right
thumb of choice. The tip of the thumb is put
vertically into the sulcus ; the active phase of the
deep friction is a transverse movement towards the
left or the right.
The sulcus can always be felt, but the tendon may
not be felt.
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Foot and ankle techniques
Gastrocnemius muscle belly friction
massage
Starting position : plantarflexion and slight knee
flexion. The DF is the normal execution, carried
out with all fingers, regardless of the size of the
lesion. In such a way the risk of adhesions is
significantly smaller. Make sure to take enough
reserve of skin, so that the range can be big
enough. The DF-movement can be guided by a
body-movement.
Achilles tendon medial/lateral aspect friction massage
The therapist can either stand or sit. The thigh
immobilizes the foot in dorsiflexion in order to bring
some tension in the tendon. The DF is a pinching
technique with thumb and index finger, reinforced
by the middle finger. A large reserve of skin is given
in an anterior direction, then pressure is applied and
the active phase of the DF is a straight movement
backwards. For the patient's comfort it is important
that the therapist's DIP-joints are not flexed too
much. To avoid damage to the skin it is necessary
to use a thin layer of cotton wool between fingers
and skin.
This technique is best performed with both hands
simultaneously. After having pushed the skin
forwards, the therapist's arms are almost extended.
Achilles tendon anterior medial/lateral
aspect friction massage
In plantiflexion the tendon is pushed medially
by the therapist's thumb ; in this way the
necessary space can be created. The contact
with the thumb is not sharp, but flat. The DF is
performed with the ring finger reinforced by
the middle finger. First, a reserve of skin is
taken in pronation, then pressure is applied ;
the active phase of the DF is a supination
movement.
It is very important that the therapist's
forearm remains parallel to the patient's leg.
Therefore the couch is put in a rather high
position to enhance the therapist's comfort.
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Achilles tendon insertion friction massage
The starting position is once more plantiflexion. The DF is
the normal execution with both index fingers. Fingers and
thumbs form a circle, pressure is applied towards the
toes. The finger feels tendon and bone at the same time.
Peronei proximal aspect friction massage
The therapist stands next to the patient. The tendons are
brought on the stretch by some plantiflexion and
adduction. The DF consists of the normal execution with
one or more fingers (depending on the size of the lesion).
Peronei distal aspect friction massage
The starting position is the same. The DF is the normal
execution with the index finger reinforced by the middle
finger.
Peronei aspect behind the malleolus friction
massage
Again, the tendons are in a stretched position. The
therapist, however, now stands in front of the patient.
This part of the tendon is treated with a supination
technique with the ring finger, reinforced by the middle
finger. All finger joints are slightly flexed. A reserve of
skin is given in pronation ; the active phase of the DF is a
supination movement.
Tibialis posterior proximal aspect friction
massage
The therapist's thigh keeps the foot in dorsiflexion.
The entire ring finger is put on the lesion and a
reserve of skin is taken in pronation ; pressure is
applied and the active phase of the DF is a
supination movement. Reinforcing the ring finger
with the fingers of the other hand makes the active
phase even more effective and certainly more
practical.
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Tibialis posterior distal aspect friction
massage
The tendon is put on stretch by bringing the foot in
dorsiflexion. The DF is the normal execution with one or
two fingers, depending on the size of the lesion.
Anterior talofibular ligament fibular insertion
friction massage
The ligament is put on the stretch by a
plantiflexion-adduction-supination movement. We
palpate the ligament along the fibular edge. The DF
is the normal execution with the index finger
reinforced by the middle finger, and the thumb
acting as a fulcrum. The thumb is put in such a way
that the DF is given in a 45° direction to the foot.
The index finger feels bone (fibula) and ligament at
the same time.
Anterior talofibular ligament talar insertion
friction massage
The starting position is the same. By changing the
position of the thumb, the DF is now given in a 90°
direction to the foot (instead of the 45° of the previous
technique). The index finger feels talus and ligament at
the same time.
Calcaneofibular ligament friction massage
The homolateral hand keeps the heel in varus. The DF is
the normal execution with the ring finger reinforced by
the middle finger, and the thumb acting as a fulcrum.
The thumb is put anteriorly on the patient's leg in such a
way that the direction of the DF is towards the patient's
heterolateral shoulder. The finger has ligament and bone
contact.
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Calcaneocuboid ligament friction massage
The foot is kept in some mid-tarsal adduction.
Palpation : we stand medially to the patient's foot.
We place our heterolateral thumb first on the head
of the fifth metatarsal bone, then next to it
(proximal) ; now the joint line between cuboid and
calcaneus lies just proximal to our thumb. Our index
finger palpates along the joint line from the sole to
the dorsum of the foot : first a peroneal tendon is
felt, then bone and eventually a flat soft structure,
which is the calcaneocuboid ligament.
The DF is the normal execution with the index finger reinforced by the middle
finger, and the thumb acting as a fulcrum.
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